Provider Demographics
NPI:1144283524
Name:CLINT VANLANDINGHAM
Entity type:Organization
Organization Name:CLINT VANLANDINGHAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:VANLANDINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:573-785-4546
Mailing Address - Street 1:2600 KANELL BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3001
Mailing Address - Country:US
Mailing Address - Phone:573-785-4546
Mailing Address - Fax:
Practice Address - Street 1:2600 KANELL BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3001
Practice Address - Country:US
Practice Address - Phone:573-785-4546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MO2004001321213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO00014615Medicare PIN
MO5472780001Medicare NSC